Grave’s disease is an autoimmune disease caused by stimulatory TSH (Thyroid Stimulating Hormone)-receptor antibodies. It is one of the causes of thyrotoxicosis. The incidence is 9 females to 1 male. It commons in women and men age between 30-50 years old.
On examination, diffuse thyroid enlargement can be seen (neck lump). Most of the time the patient will by hyperthyroid, however, the patient may also present as hypo or euthyroid (normal thyroid function). Grave’s disease also associated with some other autoimmune diseases such as vitiligo, type 1 diabetes mellitus and addison’s disease.
Disease manifestations:
1. Eye disease:
· exophthalmus (staring appearance)
· ophthalmoplegia (pain on movement of the eye ball)
2. Pretibial myxoedema – oedematous swellings above the lateral malleoli
3. Thyroid acropachy – extreme manifestations
· Clubbing (deformity of the nail)
· Painful finger
· Toe swelling
· Periosteal reaction in limb bones
Other relevant topics:
· Thyrotoxicosis
· Graves’ disease
· Toxic mutinodular goiter
· Toxic adenoma
· Thyroid storms
Reference:
1. Oxford handbook of Clinical Medicine. 7th edition. Oxford University Press. 2008.
Thyroid crisis is an emergency. It precipitates by recent surgery of thyroid or radioiodine treatment. Infection, myocardial infarction and trauma may also lead to thyroid storm in active hyperthyroidism patient.
Signs and symptoms:
· Severe hyperthyroidism
· Fever
· Agitation
· Confusion
· Coma
· Tachycardia (heart rate >100 per minute)
· Fast atrial fibrillation
· Diarrhea
· Vomiting
· Goitre
· Thyroid bruit
· Similar symptoms of acute abdomen
Isotope scan is needed to confirm the diagnosis (technetium uptake). However, in urgent or acute case, we shouldn’t wait for the scan before initiation of treatment.
Management:
· IV infusion of 1 pint normal saline over 4 hours
· Nasogastric tube insertion if recurrent vomiting present
· Do blood investigations for TSH/T4/T3, consider blood cultures and sensitivity if there is any suspicion of underlying infection
· In certain cases, sedation is indicated (eg: chlorpromazine)
· Tablet propanolol 40mg 8 hourly should be given if no contraindication (maximum IV dose: 1mg/min, repeated up to 9 times at >2minutes intervals)
· High dose digoxin (eg: IV infusion 1mg/2 hours) – to slow heart rate
· Give antithyroid drugs: tablet carbimazole 15-25mg stat and 6 hourly by oral (or nasogastric tube)
· After 4 hours of first dose, give Lugol’s solution 0.3ml/8 hourly for a week. This is needed to block the thyroid
· Give IV hydrocortisone 100mg/6 hourly or tablet dexamethasone 4mg 6 hourly
· If any suspicion of infection, treat with IV antibiotic
· Reassess the need of fluid infusion and adjust accordingly
· Relief the fever by tepid sponging and paracetamol
· After 5 days, tablet carbimazole dose should be reduce to 15mg/8 hourly
· After 10 days of treatment, stop iodine and propanolol (if heart rate is normal). Carbimazole dose should be adjusted accordingly
Other relevant topics:
· Thyrotoxicosis
· Graves’ disease
· Toxic mutinodular goiter
· Toxic adenoma
· Thyroid storm
Reference:
1. Oxford handbook of Clinical Medicine. 7th edition. Oxford University Press. 2008.
